Members can use the claim forms for services rendered by in-area or out-of-area non-participating providers. Participating providers are responsible for filing claims for their services. Claim forms should not be used for services rendered through any discount Dental or Vision program or for the Options program for alternative therapies. The discount is applied by the provider at the time of service for such programs.
Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.
Medigap/Supplemental 65 Claim Forms
If you need a form that is currently not available online, please call Member Services at the telephone number on your ID card.